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Papers by Chris Kapelios

International Journal of Cardiology, 2015

Journal of the American College of Cardiology, 2013

Journal of the American College of Cardiology, 2013

Journal of the American College of Cardiology, 2012

Journal of Hypertension, 2011

The Journal of Heart and Lung Transplantation, 2013

BACKGROUND: Skeletal muscle wasting is associated with altered catabolic/anabolic balance and poo... more BACKGROUND: Skeletal muscle wasting is associated with altered catabolic/anabolic balance and poor prognosis in patients with chronic heart failure (CHF). This study evaluated catabolic and anabolic abnormalities in relation to disease severity in CHF patients. METHODS: Forty-two stable CHF patients (34 men; aged 56 Ϯ 12 years, body mass index, 27 Ϯ 5 kg/m 2 ) receiving optimal medical treatment underwent incremental symptom-limited cardiopulmonary exercise testing on a cycle ergometer. Blood samples were drawn within 10 days to determine serum cortisol, plasma adrenocorticotropin (ACTH), and serum dehydroepiandrosterone sulfate, insulin-like growth factor 1, growth hormone, and total testosterone in men. RESULTS: Patients with higher cortisol levels presented with impaired peak oxygen uptake (VO 2 peak : 18.3 Ϯ 3.9 vs 14.2 Ϯ 3.7 ml/kg/min, p o 0.01), ventilatory (VE) response to exercise (VE/carbon dioxide output [VCO 2 ] slope: 36 Ϯ 6 vs 30 Ϯ 5, p o 0.01), and chronotropic reserve ([peak heart rate [HR]resting HR/220 -age -resting HR] Â 100%: 40 Ϯ 19 vs 58 Ϯ 18, p ¼ 0.01) compared with those with lower serum cortisol. Cortisol was inversely correlated with VO 2 peak , (r ¼ À0.57; p o 0.01) and was correlated with VE/ VCO 2 slope (r ¼ 0.47; p o 0.01) and chronotropic reserve (r ¼ 0.44; p ¼ 0.017). In multivariate regression analysis, cortisol was an independent predictor of VO 2peak (R 2 ¼ 0.365, F ¼ 12.5, SE ¼ 3.4; p r 0.001) and VE/ VCO 2 slope (R 2 ¼ 0.154; F ¼ 8.5; SE ¼ 5.96; p ¼ 0.006), after accounting for age, body mass index, sex, CHF etiology, creatinine, left ventricular ejection fraction, and ACTH in all patients. In men, cortisol and dehydroepiandrosterone levels were both independent predictors of VO 2peak (R 2 ¼ 0.595, F ¼ 24.53, SE ¼ 2.76; p o 0.001) after accounting also for all measured hormones, whereas cortisol remained the only independent predictor of VE/ VCO 2 slope (R 2 ¼ 0.133; F ¼ 6.1; SE ¼ 6.2; p ¼ 0.02). CONCLUSIONS: Enhanced catabolic status is significantly associated with exercise intolerance, ventilatory inefficiency, and chronotropic incompetence in CHF patients, suggesting a significant contributing mechanism to their limited functional status.

International Journal of Cardiology, 2014

The intra-aortic balloon pump (IABP), which is the main representative of the counterpulsation te... more The intra-aortic balloon pump (IABP), which is the main representative of the counterpulsation technique, has been an invaluable tool in cardiologists' and cardiac surgeons' armamentarium for approximately half a century. The IABP confers a wide variety of vaguely understood effects on cardiac physiology and mechano-energetics. Although, the recommendations for its use are multiple, most are not substantially evidence-based. Indicatively, the results of recently performed prospective studies have put IABP's utility in the setting of post-infarction cardiogenic shock into question. However, the particular issue remains open to further research. IABP support in high-risk patients undergoing PCI is associated with favorable long-term clinical outcome. In cardiac surgery, the use of IABP in cases of peri-operative low-output syndrome, refractory angina or ischemia-related mechanical complications is a usual, but poorly justified strategy. Anecdotal cases of treatment of incessant ventricular arrhythmias, reversal of right ventricular dysfunction and partial myocardial recovery have also been reported with its use. Converging data demonstrate the potential of safe long-term IABP support as a bridge to decision making or a bridge to transplantation modality in patients with heart failure. The feasibility of IABP insertion via other than the femoral artery sites enhances this potential. Despite the fact that several other counterpulsation devices have been developed and tested overtime none has managed to substitute the IABP, which continues to be most frequently used mechanical assist device.

European Journal of Heart Failure, 2012

Chronic heart failure (CHF) is associated with increased risk of osteoporosis. We investigated th... more Chronic heart failure (CHF) is associated with increased risk of osteoporosis. We investigated the relationship between severity of CHF and bone loss, underlying pathophysiological mechanisms, and the prognostic significance of bone mass changes in heart failure. Total body (TB) and femoral (F) bone mineral density (BMD), and T- and Z-scores in the femur were measured in 60 men with CHF (56 ± 11 years) and 13 age-matched men free from CHF. The composite study endpoint was death, implantation of a left ventricular assist device (LVAD), or inotrope dependency during a median 2-year follow-up. Parathyroid hormone (PTH) and vitamin D were measured in all subjects. TBBMD, FBMD, T-score, and Z-score were significantly lower in men with CHF. Their PTH levels were also significantly increased (111 ± 59 vs. 39 ± 14; P < 0.001). Patients in New York Heart Association classes III-IV compared with those in classes I-II demonstrated significantly lower TBBMD, FBMD, T-score, and Z-score, and higher PTH (136 ± 69 vs. 86 ± 31; P= 0.001). Increased PTH levels were correlated with reduced TBBMD (P = 0.003), FBMD (P = 0.002), and femur T-score (P = 0.001), reduced cardiac index (P = 0.01) and VO(2) peak (P < 0.0001), and increased wedge pressure (P = 0.001). Low TBBMD [hazard ratio (HR) 0.003, 95% confidence interval (CI) 0.00-0.58; P = 0.03] and Z-score (HR 0.56, 95% CI 0.35-0.90; P = 0.017) were associated with adverse outcome. Secondary hyperparathyroidism and reduction in bone density occur in CHF patients and are associated with disease severity. Increased bone mass loss in CHF has prognostic significance.

Current Opinion in Cardiology, 2014

The intra-aortic balloon pump (IABP) has been used for more than 40 years. Although recommended i... more The intra-aortic balloon pump (IABP) has been used for more than 40 years. Although recommended in a wide variety of clinical settings, most of these indications are not evidence-based. This review focuses on studies challenging these traditional indications and evaluates potentially new applications of intra-aortic counterpulsation. Recent studies have failed to confirm an improvement in clinical outcomes conferred by the IABP in patients developing cardiogenic shock after acute myocardial infarction. This issue is in need of further investigations. While conflicting results of several retrospective studies and meta-analyses have been published regarding the performance of the IABP in high-risk percutaneous coronary interventions, it has recently been found to improve the long-term clinical outcomes of patients in whom it was implanted before the procedure. Small, single-center studies have reported the use of the IABP as a bridge to transplantation or candidacy for left-ventricular assist device implantation. The recently reported feasibility and safety of its insertion via the subclavian or axillary arteries will facilitate these applications. The revisiting of available data and the performance of new, thoughtfully designed trials should clarify the proper indications for the IABP.

The Journal of Heart and …, 2011

BACKGROUND: Several skeletal muscle abnormalities have been identified in patients with chronic h... more BACKGROUND: Several skeletal muscle abnormalities have been identified in patients with chronic heart failure (CHF), including endothelial dysfunction. We hypothesized that skeletal muscle microcirculation, assessed by near-infrared spectroscopy (NIRS), is impaired in CHF patients and is associated with disease severity. METHODS: Eighty-three stable patients with mild-moderate CHF (72 males, mean age 54 Ϯ 14 years, body mass index 26.7 Ϯ 3.4 kg/m 2 ) and 8 healthy subjects, matched for age, gender and body mass index, underwent NIRS with the vascular occlusion technique and cardiopulmonary exercise testing (CPET) evaluation on the same day. Tissue oxygen saturation (StO 2 , %), defined as the percentage of hemoglobin saturation in the microvasculature compartments, was measured in the thenar muscle by NIRS before, during and after 3-minute occlusion of the brachial artery. Measurements included StO 2 , oxygen consumption rate (OCR, %/min) and reperfusion rate (RR, %/min). All subjects underwent a symptom-limited CPET on a cycle ergometer. Measurements included VO 2 at peak exercise (VO 2 peak, ml/kg/min) and anaerobic threshold (VO 2 AT, ml/kg/min), VE/VCO 2 slope, chronotropic reserve (CR, %) and heart rate recovery (HRR 1 , bpm). RESULTS: CHF patients had significantly lower StO 2 (75 Ϯ 8.2 vs 80.3 Ϯ 6, p Ͻ 0.05), lower OCR (32.3 Ϯ 10.4 vs 37.7 Ϯ 5.5, p Ͻ 0.05) and lower RR (10 Ϯ 2.8 vs 15.7 Ϯ 6.3, p Ͻ 0.05) compared with healthy controls. CHF patients with RR Ն9.5 had a significantly greater VO 2 peak (p Ͻ 0.001), VO 2 AT (p Ͻ 0.01), CR (p ϭ 0.01) and HRR 1 (p ϭ 0.01), and lower VE/VCO 2 slope (p ϭ 0.001), compared to those with RR Ͻ9.5. In a multivariate analysis, RR was identified as an independent predictor of VO 2 peak, VE/VCO 2 slope and HRR 1 . CONCLUSIONS: Peripheral muscle microcirculation, as assessed by NIRS, is significantly impaired in CHF patients and is associated with disease severity.

International Journal of Cardiology, 2015

Journal of the American College of Cardiology, 2013

Journal of the American College of Cardiology, 2013

Journal of the American College of Cardiology, 2012

Journal of Hypertension, 2011

The Journal of Heart and Lung Transplantation, 2013

BACKGROUND: Skeletal muscle wasting is associated with altered catabolic/anabolic balance and poo... more BACKGROUND: Skeletal muscle wasting is associated with altered catabolic/anabolic balance and poor prognosis in patients with chronic heart failure (CHF). This study evaluated catabolic and anabolic abnormalities in relation to disease severity in CHF patients. METHODS: Forty-two stable CHF patients (34 men; aged 56 Ϯ 12 years, body mass index, 27 Ϯ 5 kg/m 2 ) receiving optimal medical treatment underwent incremental symptom-limited cardiopulmonary exercise testing on a cycle ergometer. Blood samples were drawn within 10 days to determine serum cortisol, plasma adrenocorticotropin (ACTH), and serum dehydroepiandrosterone sulfate, insulin-like growth factor 1, growth hormone, and total testosterone in men. RESULTS: Patients with higher cortisol levels presented with impaired peak oxygen uptake (VO 2 peak : 18.3 Ϯ 3.9 vs 14.2 Ϯ 3.7 ml/kg/min, p o 0.01), ventilatory (VE) response to exercise (VE/carbon dioxide output [VCO 2 ] slope: 36 Ϯ 6 vs 30 Ϯ 5, p o 0.01), and chronotropic reserve ([peak heart rate [HR]resting HR/220 -age -resting HR] Â 100%: 40 Ϯ 19 vs 58 Ϯ 18, p ¼ 0.01) compared with those with lower serum cortisol. Cortisol was inversely correlated with VO 2 peak , (r ¼ À0.57; p o 0.01) and was correlated with VE/ VCO 2 slope (r ¼ 0.47; p o 0.01) and chronotropic reserve (r ¼ 0.44; p ¼ 0.017). In multivariate regression analysis, cortisol was an independent predictor of VO 2peak (R 2 ¼ 0.365, F ¼ 12.5, SE ¼ 3.4; p r 0.001) and VE/ VCO 2 slope (R 2 ¼ 0.154; F ¼ 8.5; SE ¼ 5.96; p ¼ 0.006), after accounting for age, body mass index, sex, CHF etiology, creatinine, left ventricular ejection fraction, and ACTH in all patients. In men, cortisol and dehydroepiandrosterone levels were both independent predictors of VO 2peak (R 2 ¼ 0.595, F ¼ 24.53, SE ¼ 2.76; p o 0.001) after accounting also for all measured hormones, whereas cortisol remained the only independent predictor of VE/ VCO 2 slope (R 2 ¼ 0.133; F ¼ 6.1; SE ¼ 6.2; p ¼ 0.02). CONCLUSIONS: Enhanced catabolic status is significantly associated with exercise intolerance, ventilatory inefficiency, and chronotropic incompetence in CHF patients, suggesting a significant contributing mechanism to their limited functional status.

International Journal of Cardiology, 2014

The intra-aortic balloon pump (IABP), which is the main representative of the counterpulsation te... more The intra-aortic balloon pump (IABP), which is the main representative of the counterpulsation technique, has been an invaluable tool in cardiologists' and cardiac surgeons' armamentarium for approximately half a century. The IABP confers a wide variety of vaguely understood effects on cardiac physiology and mechano-energetics. Although, the recommendations for its use are multiple, most are not substantially evidence-based. Indicatively, the results of recently performed prospective studies have put IABP's utility in the setting of post-infarction cardiogenic shock into question. However, the particular issue remains open to further research. IABP support in high-risk patients undergoing PCI is associated with favorable long-term clinical outcome. In cardiac surgery, the use of IABP in cases of peri-operative low-output syndrome, refractory angina or ischemia-related mechanical complications is a usual, but poorly justified strategy. Anecdotal cases of treatment of incessant ventricular arrhythmias, reversal of right ventricular dysfunction and partial myocardial recovery have also been reported with its use. Converging data demonstrate the potential of safe long-term IABP support as a bridge to decision making or a bridge to transplantation modality in patients with heart failure. The feasibility of IABP insertion via other than the femoral artery sites enhances this potential. Despite the fact that several other counterpulsation devices have been developed and tested overtime none has managed to substitute the IABP, which continues to be most frequently used mechanical assist device.

European Journal of Heart Failure, 2012

Chronic heart failure (CHF) is associated with increased risk of osteoporosis. We investigated th... more Chronic heart failure (CHF) is associated with increased risk of osteoporosis. We investigated the relationship between severity of CHF and bone loss, underlying pathophysiological mechanisms, and the prognostic significance of bone mass changes in heart failure. Total body (TB) and femoral (F) bone mineral density (BMD), and T- and Z-scores in the femur were measured in 60 men with CHF (56 ± 11 years) and 13 age-matched men free from CHF. The composite study endpoint was death, implantation of a left ventricular assist device (LVAD), or inotrope dependency during a median 2-year follow-up. Parathyroid hormone (PTH) and vitamin D were measured in all subjects. TBBMD, FBMD, T-score, and Z-score were significantly lower in men with CHF. Their PTH levels were also significantly increased (111 ± 59 vs. 39 ± 14; P < 0.001). Patients in New York Heart Association classes III-IV compared with those in classes I-II demonstrated significantly lower TBBMD, FBMD, T-score, and Z-score, and higher PTH (136 ± 69 vs. 86 ± 31; P= 0.001). Increased PTH levels were correlated with reduced TBBMD (P = 0.003), FBMD (P = 0.002), and femur T-score (P = 0.001), reduced cardiac index (P = 0.01) and VO(2) peak (P < 0.0001), and increased wedge pressure (P = 0.001). Low TBBMD [hazard ratio (HR) 0.003, 95% confidence interval (CI) 0.00-0.58; P = 0.03] and Z-score (HR 0.56, 95% CI 0.35-0.90; P = 0.017) were associated with adverse outcome. Secondary hyperparathyroidism and reduction in bone density occur in CHF patients and are associated with disease severity. Increased bone mass loss in CHF has prognostic significance.

Current Opinion in Cardiology, 2014

The intra-aortic balloon pump (IABP) has been used for more than 40 years. Although recommended i... more The intra-aortic balloon pump (IABP) has been used for more than 40 years. Although recommended in a wide variety of clinical settings, most of these indications are not evidence-based. This review focuses on studies challenging these traditional indications and evaluates potentially new applications of intra-aortic counterpulsation. Recent studies have failed to confirm an improvement in clinical outcomes conferred by the IABP in patients developing cardiogenic shock after acute myocardial infarction. This issue is in need of further investigations. While conflicting results of several retrospective studies and meta-analyses have been published regarding the performance of the IABP in high-risk percutaneous coronary interventions, it has recently been found to improve the long-term clinical outcomes of patients in whom it was implanted before the procedure. Small, single-center studies have reported the use of the IABP as a bridge to transplantation or candidacy for left-ventricular assist device implantation. The recently reported feasibility and safety of its insertion via the subclavian or axillary arteries will facilitate these applications. The revisiting of available data and the performance of new, thoughtfully designed trials should clarify the proper indications for the IABP.

The Journal of Heart and …, 2011

BACKGROUND: Several skeletal muscle abnormalities have been identified in patients with chronic h... more BACKGROUND: Several skeletal muscle abnormalities have been identified in patients with chronic heart failure (CHF), including endothelial dysfunction. We hypothesized that skeletal muscle microcirculation, assessed by near-infrared spectroscopy (NIRS), is impaired in CHF patients and is associated with disease severity. METHODS: Eighty-three stable patients with mild-moderate CHF (72 males, mean age 54 Ϯ 14 years, body mass index 26.7 Ϯ 3.4 kg/m 2 ) and 8 healthy subjects, matched for age, gender and body mass index, underwent NIRS with the vascular occlusion technique and cardiopulmonary exercise testing (CPET) evaluation on the same day. Tissue oxygen saturation (StO 2 , %), defined as the percentage of hemoglobin saturation in the microvasculature compartments, was measured in the thenar muscle by NIRS before, during and after 3-minute occlusion of the brachial artery. Measurements included StO 2 , oxygen consumption rate (OCR, %/min) and reperfusion rate (RR, %/min). All subjects underwent a symptom-limited CPET on a cycle ergometer. Measurements included VO 2 at peak exercise (VO 2 peak, ml/kg/min) and anaerobic threshold (VO 2 AT, ml/kg/min), VE/VCO 2 slope, chronotropic reserve (CR, %) and heart rate recovery (HRR 1 , bpm). RESULTS: CHF patients had significantly lower StO 2 (75 Ϯ 8.2 vs 80.3 Ϯ 6, p Ͻ 0.05), lower OCR (32.3 Ϯ 10.4 vs 37.7 Ϯ 5.5, p Ͻ 0.05) and lower RR (10 Ϯ 2.8 vs 15.7 Ϯ 6.3, p Ͻ 0.05) compared with healthy controls. CHF patients with RR Ն9.5 had a significantly greater VO 2 peak (p Ͻ 0.001), VO 2 AT (p Ͻ 0.01), CR (p ϭ 0.01) and HRR 1 (p ϭ 0.01), and lower VE/VCO 2 slope (p ϭ 0.001), compared to those with RR Ͻ9.5. In a multivariate analysis, RR was identified as an independent predictor of VO 2 peak, VE/VCO 2 slope and HRR 1 . CONCLUSIONS: Peripheral muscle microcirculation, as assessed by NIRS, is significantly impaired in CHF patients and is associated with disease severity.